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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610177
Report Date: 07/13/2021
Date Signed: 07/13/2021 11:00:54 AM

Document Has Been Signed on 07/13/2021 11:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANNA'S HOME & PARADISEFACILITY NUMBER:
197610177
ADMINISTRATOR:ARMENYAN, ANNAFACILITY TYPE:
740
ADDRESS:23463 HAYNES STREETTELEPHONE:
(323) 660-0001
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 2DATE:
07/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Melissa Ruiz, Patrick Shanahan and Angela Panushkina conducted an announced Pre-Licensing visit to this facility and met with administrator Anna Armenyan. Application was received for six (6) total residents, of which five (5) are non-ambulatory and one (1) may be bedridden.
Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.
The facility is a single-story building, Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following:
The fire extinguisher is located in the dining area and was observed to be fully charged and was bought on 04/02/2021. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational at approximately 9:30 a.m. Hot water was tested in the common bathrooms and measured at 115°F. There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted near the entrance wall with other posting requirements. There are 5 resident bedrooms, 4 private and 1 shared room. No room is designated for staff use. Resident bedrooms were observed to be appropriately furnished with a bed, nightstand, a chair and extra linens. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177
VISIT DATE: 07/13/2021
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Resident and staff records will be stored and locked in a file cabinet near the kitchen. Medications will be stored in a locked pantry near the kitchen as well. The first aid kit is readily available. There are 2 bathrooms in the facility. The common bathrooms have non-skid mats, trash cans with lids and functional grab bars. The sharps, are stored and locked in the pantry. Kitchen cleaning supplies, laundry detergents, cleaning supplies and other toxins are stored and locked in the garage. The laundry is located in the hallway and appears to be functional. The facility has a variety of adequate perishable and non-perishable food supply. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Appliances in the kitchen appeared to be functional. Facility appears to be clean and in good repair.

There is a large sitting area and a large gardening area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house but is kept locked from the inside. There is no body of water in the facility.



Component III was conducted with the administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with administrator Anna Armenya and a copy of this report was provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
LIC809 (FAS) - (06/04)
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